What is communication ? Exchange of information with others produce understand messages
Forms of communication Nonlinguistic (gestures, body posture, facial expression, eye contact, head and body movement) Verbal = words (speaking, writing, sign language) Paralinguistic (tone of voice, emphasis of words)
Communication development Signals: joint attention, gestural communication, turn-taking Language comprehension Language production The ability to understand develops before the ability to speak !! !! !!
Communication Communication varies with the child ’ s age and developmental status
Speech milestones 1 to 6 months 6 to 9 months 10 to 11 months 12 months 13 to 15 months 16 to 18 months 19 to 21 months 22 to 24 months Coos in response to voice Babbling says "mama/dada”, no meaning Says "mama/dada" with meaning Four to seven words & jargon 10 words, some echolalia, jargon Vocabulary of 20 words Two-word phrases, vocabulary>50
Speech milestones 2 to 2 1/2 years 2 1/2 to 3 years 3 to 4 years 4 to 5 years 400 words, two- to three-word phrases, use of pronouns Plurals and past tense, knows age and sex, 3-5 words per sentence 3-6 words per sentence, asks questions, tells stories 6-8 words per sentence, names four colors, counts 10 pennies correctly
Signs of concern Not babbling by 12 to 15 months Not comprehending simple commands by the age of 18 months Not talking by 2 years Not making sentences by 3 years Difficulty telling a simple story by 4-5 years
Speech delay Speech delay is defined as the failure to acquire words by 18-24 months of age or phrases by 3 years of age Delayed acquisition of speech is not always due to late maturation in children !
The impact of communication disorder The communication has a long-term impact on: –learning (reading) –social interaction
Communication Language - rule-based system of symbolic communication involving a set of small units Speech - oral production & articulation of words
Improper use of words and their meanings Inability to express ideas Inappropriate grammatical patterns Reduced vocabulary Inability to follow directions Dysfluency Articulation or phonological disorders Difficulties with the pitch, volume or quality of the voice Language disordersSpeech disorders
Major types of communication disorders Language disorders (60%) –general language delay (MR, autism, DD) –specific language impairment (expressive, receptive + expressive) Speech disorders (40%) Hearing disorders
Epidemiology of communication disorders The most common developmental problem in young children (25-50%) The disorder is 3-4 times more common in boys than in girls Early identification and early intervention are important
Language variations Familiar setting during examination ! Cultural background Bilingualism Maturation delay - Late talkers
Bilingualism A temporary delay in the onset of both languages Comprehension of the two languages is normal The child usually becomes proficient in both languages before 5 years Children cannot have a communication disorder in one language alone
Causes of language disorders Hearing loss Mental retardation Autism /PDD Acquired brain damage (left hemisphere) Expressive language disorder Receptive aphasia Specific language impairment Seizures CP Elective mutism Psychosocial deprivation
Hearing Loss The most frequently overlooked disorder affecting speech development Common causes: recurring middle ear infections, congenital malformations, meningitis, trauma, genetic disorders Diagnosis - behavioral or physiologic audiometry
Hearing Loss Suspect hearing loss when a child does not seem to understand; is inattentive; looks intently at others who are speaking; or better recognizes sounds with more lip movement, such as the letter W.
Developmental Delay Speech delay caused by late maturation can be mild, moderate, severe, or very severe, depending on the level of impairment of word sounds, spoken language, and language comprehension.
Mental Retardation Over half of all mentally retarded children are speech delayed Speech development is relatively more delayed in MR children than are other fields of development Generalized delay suggests mental retardation as the cause of a child's speech delay
Mental retardation Don't overlook common coexisting contributors such as: deafness, dysarthria, or sensory deprivation Global language delay, delayed auditory comprehension and delayed use of gestures
Pervasive Developmental Disorders DSM-IV Autistic disorder PDD-NOS (Pervasive developmental disorder-not otherwise specified) Asperger ’ s disorder Rett ’ s syndrome Childhood disintegrative disorder (Heller ’ s syndrome)
Autism Onset before 36 months (18-30 mo.) Prevalence 1-2:1000 Autism is more common in boys (3-4:1) Recurrence risk in families 3-8% Biologic cause in 10-30%: genetic syndromes, congenital infections, HIE, neurocutaneus, metabolic, epileptic
Autism Onset occurs before 36 months Autistic children fail to make eye contact, smile socially, respond to being hugged or use gestures to communicate Ritualistic and compulsive behaviors, including stereotyped repetitive motor activity Autism is three to four times more common in boys than in girls
Autism-clinical Impairment in social interaction Impairment in language & communication Restricted, repetitive & stereotyped pattern of behavior, interest & activities
Autism & language About half of autistic children don't develop useful speech by age 5 and have a poor prognosis Speech abnormalities: echolalia, perseveration, pronoun confusion, abnormalities of prosody, semantic pragmatic disorder
Cerebral Palsy Delay in speech is common in CP Speech delay occurs most often in athetoid type of CP Factors that may account for the speech delay: hearing loss, spasticity or incoordination of the muscles of the tongue, coexisting MR or a defect in the cerebral cortex
Left Cerebral Lesion If acquired before 6 years, left-brain lesions shift the language center to the right hemisphere May cause speech delay and "pathologic" left-handedness (too early or without a family history of left-handedness) Aphasia, the loss of previously acquired speech, is almost always traced to a left cerebral lesion
Seizures When these begin in the first decade, they can cause delayed speech or aphasia and can result in verbal auditory agnosia (word deafness)
Elective mutism These children are negativistic, shy, timid and withdrawn Symptoms of poor adjustment, such as poor peer relationships or overdependence on their parents Anxiety, attention seeking, or embarrassment about a speech deficit Usually family psychopathology Can persist for months or years
Psychosocial Factors Speech development can be slower in: –twins –younger siblings –children in lower socioeconomic classes –children of deaf-mute parents –children exposed to more than one language.
Language regression Autistic regression Landau Kleffner - Aquired epileptic aphasia ESES - Electrical status epilepticus in sleep Disintegrative disorder
Specific language impairment = Developmental language disorders (DLD) 5-10% of preschooler Difficulties in language acquisition (without hearing impairment, low intelligence and neurological damage) Diagnosis by exclusion Risk for reading/academic difficulty & social failure
Developmental language disorders (DLD) - major types Phonology-syntactic: –Mixed receptive-expressive (verbal auditory agnosia) –Expressive only (verbal dyspraxia) Higher order processing (semantic- pragmatic): –Autistic spectrum
Receptive Aphasia-word deafness A deficit in comprehension of spoken language with normal responses to nonverbal auditory stimuli The speech is delayed, sparse, agrammatic and indistinct in articulation Most children with gradually acquire a language of their own, understood only by those who are familiar with them
Prognosis Expressive delay alone resolve spontaneously in the pre-school period A poorer prognosis for children with expressive/receptive delays It is not possible to predict at the time of identification, which of the children with expressive delay are likely to have persistent problems
Diagnostic evaluation Audiometry with special earphones Tympanometry An auditory brain-stem response Imaging modalities are not indicated Prolonged sleep EEG is indicated in language regression (subclinical epileptiform EEG) All children with speech delay should be referred for audiometry
Diagnostic evaluation Additional tests should be ordered only when they are indicated A karyotype for chromosomal abnormalities and a DNA test in children who have the phenotypic appearance of fragile X synd. An EEG should be considered in children with seizures or with significant receptive language disabilities or language regression (subclinical seizure activities)
Developmental language disorders - etiology Genetic ! Twin studies (96% concordance in MZ, 69% in DZ) Linkage to chromosome 7q31 FOXP2 gene (Nature 413:4 oct,2001)